感觉障碍、孤独感与躯体-心理-认知多重共病的出现：一项在中国、美国和英国开展的多国队列研究

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中文摘要

背景： 躯体疾病、心理障碍和认知损害的共现——此处称为躯体-心理-认知多重共病（PPC-M）——对健康老龄化构成日益严峻的挑战，但其上游可改变的决定因素仍研究不足。感觉障碍在晚年常见，可能通过孤独感等心理社会因素部分地与PPC-M的出现相关。本研究旨在三个国家老龄化队列中检验视力、听力和双重感觉障碍与 incident PPC-M 的关联，并评估孤独感是否部分解释这些关联。
方法： 我们分析了来自三个具有全国代表性的老龄化队列——CHARLS（中国）、HRS（美国）和ELSA（英国）——的15,022名年龄≥45岁的成年人，随访6-8年。视力障碍（VI）、听力障碍（HI）和双重感觉障碍（DSI）在基线时自我报告。incident PPC-M模式包括：躯体-心理（P1P2）、躯体-认知（P1C）、心理-认知（P2C）和三元共病（P1P2C）。我们拟合Cox比例风险模型和多状态生存模型，调整人口学因素、教育水平、婚姻状况和健康行为。孤独感使用协调化测量评估，并在反事实中介框架中检验为中介变量。敏感性分析包括倾向评分匹配、死亡竞争风险和暴露与结局的替代定义。
结果： 基线时，52.8%报告无感觉障碍，10.9%仅HI，17.2%仅VI，19.1% DSI。在PPC-M结局中呈现梯度关联。与无损害相比，DSI与P1P2（HR=2.18）、P2C（HR=2.36）和P1P2C（HR=1.56；95% CI：1.19-2.03）的关联最强，VI通常比HI显示更强的关联。结果在各国方向一致，并在敏感性分析中稳健。孤独感在统计上解释了各损害类型中所观察关联的约10-12%，提示潜在的心理社会解释路径。多状态模型提示DSI患者从单域状况向合并多重共病的转变加速。
解释： 感觉障碍——尤其是双重障碍——与PPC-M的发生和进展独立相关。孤独感在这些关联中占相当比例，提示其作为风险分层和干预的潜在靶点。将可及且负担得起的视力/听力服务与减少孤独感的策略相结合，可能有助于识别复杂多重共病风险升高的老年人，并为不同环境下的公平健康老龄化策略提供信息。

英文摘要

BACKGROUND: The co-occurrence of physical diseases, psychological disorders, and cognitive impairment-here termed physical-psychological-cognitive multimorbidity (PPC-M)-poses growing challenges to healthy aging but its upstream, modifiable determinants remain underexplored. Sensory impairments are common in later life and may be associated with the emergence of PPC-M, partly through psychosocial factors such as loneliness. This study aimed to examine the associations of vision, hearing, and dual sensory impairments with incident PPC-M and to assess whether loneliness partly explains these associations in three national ageing cohorts.
METHODS: We analyzed 15,022 adults aged ≥ 45 years from three nationally representative aging cohorts-CHARLS (China), HRS (United States), and ELSA (England)-followed for 6-8 years. Vision impairment (VI), hearing impairment (HI), and dual sensory impairment (DSI) were self-reported at baseline. Incident PPC-M patterns included: physical-psychological (P1P2), physical-cognitive (P1C), psychological-cognitive (P2C), and triple comorbidity (P1P2C). We fitted Cox proportional hazards models and multi-state survival models, adjusting for demographic factors, educational level, marital status, and health behaviours. Loneliness was assessed using harmonized measures and tested as a mediator within a counterfactual mediation framework. Sensitivity analyses included propensity score matching, competing risk of death, and alternative definitions of exposures and outcomes.
FINDINGS: At baseline, 52.8% reported no sensory impairment, 10.9% HI only, 17.2% VI only, and 19.1% DSI. A graded association emerged across PPC-M outcomes. Compared with no impairment, DSI showed the strongest associations with P1P2 (HR = 2.18), P2C (HR = 2.36), and P1P2C (HR = 1.56; 95% CI: 1.19-2.03), with VI generally showing stronger associations than HI. Results were directionally consistent across countries and robust in sensitivity analyses. Loneliness statistically accounted for approximately 10-12% of the observed associations across impairment types, suggesting a potential psychosocial explanatory pathway. Multi-state models suggested accelerated transitions from single-domain conditions to combined multimorbidity among those with DSI.
INTERPRETATION: Sensory impairments-especially dual impairment-were independently associated with the onset and progression of PPC-M. Loneliness accounted for a meaningful share of these associations, suggesting a potential target for risk stratification and intervention. Integrating accessible and affordable vision/hearing services with loneliness-reduction strategies may help identify older adults at elevated risk of complex multimorbidity and inform equitable healthy-aging strategies across diverse settings.